REPORTING ACT DISCLOSURE STATEMENT
In accordance with the previous Sections 604(b)(2)(A) of the Fair Credit
Reporting Act, (Public Law 91-508), as amended by the Consumer Credit Reporting
Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are
being informed that reports verifying your previous employment, driving record
and previous drug and alcohol test results may be obtained on you for employment
purposes. These reports are required by Sections 382.413, 391.25 and 391.25 of
the Federal Motor Carrier Safety Regulations.
PRE-EMPLOYMENT SCREENING PROGRAM (PSP)
The Pre-Employment Screening Program (PSP) is a screening tool that allows motor
carriers & individual drivers to purchase driving records from the Federal Motor
Carrier Safety Administration’s (FMCSA) Motor Carrier Management Information
System (MCMIS). Driver Information Resource records purchased through PSP
contain the most recent 5 years of crash data and 3 years of roadside inspection
data from the FMCSR MCMIS system.
By completing the certification below, you are certifying, that you are
authorizing a commercial driver record of crash and inspection data ("DIR") for
yourself, who is not present employee(s) of this company, solely for the
purposes of pre-employment screening.
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment with Precast Haulers, Inc.(“Prospective Employer”), Prospective
Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history
from the Federal Motor Carrier Safety Administration (FMCSA).
INVESTIGATIVE CONSUMER REPORT DISCLOSURE
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA
in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide
you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting
Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety
report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer
uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding
you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic
notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and
the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide
you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy
of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a
driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together
with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights
under the Fair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct
any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to
https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this
data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or
imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State
citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law
will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
2. I authorize Precast Haulers, Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP)
system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I
understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years
and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the
Prospective Employer to make a determination regarding my suitability as an employee.
3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has
the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by
submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot
change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
4. Please note: I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report,
or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my
PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and
remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I
sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby
authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
In connection with your employment or application for employment (including
contract for services), an investigative consumer report and consumer reports,
which may contain public record information, may be requested from DAC / USIS
Commercial Services. These reports may include the following types of
information: names and dates of previous employers, reason for termination of
employment, work experience, accidents, academic history, professional
credentials, drug/alcohol use, information relating to your character, general
reputation, personal characteristics, mode of living, educational background, or
any other information about you which may reflect upon your potential for
employment gathered from any individual, organization, entity, agency, or other
source which may have knowledge concerning any such items of information. Such
reports may contain public record information concerning your driving record,
workers' compensation claims, credit, bankruptcy proceedings, criminal records,
etc., from federal, state, and other agencies which maintain such records; as
well as information from DAC / USIS concerning previous driving record requests
made by others from such state agencies.
TO BE READ AND SIGNED BY APPLICANT
You have the right to receive, upon your written request within reasonable
period of time, (not to exceed 30 days) a complete and accurate disclosure of
the nature and scope of the investigation requested. You have the right to make
a request to DAC / USIS, upon proper identification, to request the nature and
substance of all information in its files on you at the time of your request,
including the sources of information, and the recipients of any reports on you
that DAC / USIS has previously furnished within the two-year period preceding
your request. DAC / USIS may be contacted by mail at P.O. Box 33181, Tulsa,
Oklahoma, 74153, or by phone at (800) 381-0645.
A written summary of your rights under the Fair Credit Reporting Act (FCRA) as
prepared by the Federal Trade Commission is available upon request. You also
have the right to review the information obtained from previous employers, to
correct errors in that information and rebut perceived incorrect information.
Such requests must be made in writing prior to accepting employment with the
I give the motor carrier and its agents or representatives the right to
investigate all references and to secure additional information about my
employment background. I hereby release from all liability for damages the motor
carrier and its agents or representatives for seeking such information and all
other persons, corporations or organizations for furnishing such information.
I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other such persons from all liability in responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
- Review Information provided by previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
I agree to furnish such additional information and complete such examinations as
may be required to complete my employment files.
It is agreed and understood
that this application for qualification in no way obligates the motor carrier to
It is agreed and understood that if qualified to operate motor
carrier equipment, I may be on a probationary period, during which I may be
disqualified without recourse.
Applicant's Electronic Signature: